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Healthcare Headlines: It’s Time to Make Quality Count

Written on July 22, 2013

There are many government programs with which to comply. Everyone is scrambling to meet technology standards and get incentive money associated with each program. It can be overwhelming. The Electronic Health Records Incentive Program and meaningful use requirement has been effective in getting electronic medical record technology into most practices but it has overshadowed some other important programs. The national Medical Group Management Association has asked the Department of Health and Human Services to combine programs to make it easier to participate and meet program standards.

Quality initiatives began with health plans in academic settings utilizing the Health Effectiveness Data Information Set (HEDIS). Health plans learned through this data, how prevention and disease management could improve outcomes and lower the cost of care over the lifetime of the patient. The National Committee for Quality Assurance is a private organization that drives quality objectives for employers and health plans using HEDIS measurements. These processes did not reach the private practices until Centers for Medicare & Medicaid Service (CMS) adopted the Physician Quality Reporting Initiative (PQRI).

The Physician Quality Reporting Initiative began in 2007. Participation in the program could gain physicians a 1.5% increase to their total Medicare reimbursement, but most of the medical community passed this program off as a primary care initiative. At the time, the clinical quality measures were based on preventive services or managing diseases, such as diabetes or hypertension. Incentive programs, such as PQRI, Meaningful Use and e‐prescribe are all meant to change behavior, encourage best practices, and promote adoption of technological advances in medicine.

Now known as the Physician Quality Reporting System (PQRS), the program has evolved to include 44 clinical quality measures reaching almost every specialty. Each year more measures are added to increase quality and widen the range of the program. The incentive has now decreased to .5%, and will go away after 2014. If physicians do not participate in PQRS in 2013, they will take a 1.5% cut in reimbursement in 2015. The penalty will increase to 2.0% in 2016, and subsequent years, so paying for quality is here to stay. Once you look at the clinical quality measures or CQMs you will realize it is something you most likely already do in the course of treating and caring for your patients. All you have to do is document it in a way the data can be collected. CMS is trying to help by offering simple ways to avoid the adjustment and join the program. The CMS website gives options for joining a registry to collect data, reporting through a certified electronic health record, or adopting the administrative claims option to avoid the adjustment in 2015.

Physicians often say, “I don’t have many Medicare patients” or “That won’t affect me”. All health plans now have quality initiatives. Blue Cross Blue Shield of Alabama is piloting the Primary Care Value Based Payment Program in which physicians can achieve a 15% increased fee schedule by following quality initiatives. Most shifts in healthcare start with primary care, but then spread to the specialties. We are moving to value based payment models based on documented quality measures. Physicians need to have electronic systems that track quality to enhance how they will be reimbursed in the future.